Assessment of deep dynamic mechanical sensitivity in individuals with tension-type headache: The dynamic pressure algometry.

BACKGROUND: To explore the validity of dynamic pressure algometry for evaluating deep dynamic mechanical sensitivity by assessing its association with headache features and widespread pressure sensitivity in tension-type headache (TTH). METHODS: One hundred and eighty-eight subjects with TTH (70% women) participated. Deep dynamic sensitivity was assessed with a dynamic pressure algometry set (Aalborg University, Denmark© ) consisting of 11 different rollers including fixed levels from 500 g to 5300 g. Each roller was moved at a speed of 0.5 cm/s over a 60-mm horizontal line covering the temporalis muscle. Dynamic pain threshold (DPT-level of the first painful roller) was determined and pain intensity during DPT was rated on a numerical pain rate scale (NPRS, 0-10). Headache clinical features were collected on a headache diary. As gold standard, static pressure pain thresholds (PPT) were assessed over temporalis, C5/C6 joint, second metacarpal, and tibialis anterior muscle. RESULTS: Side-to-side consistency between DPT (r = 0.843, p < 0.001) and pain evoked (r = 0.712; p < 0.001) by dynamic algometer was observed. DPT was moderately associated with widespread PPTs (0.526 > r > 0.656, all p < 0.001). Furthermore, pain during DPT was negatively associated with widespread PPTs (-0.370 < r < -0.162, all p < 0.05). DISCUSSION: Dynamic pressure algometry was a valid tool for assessing deep dynamic mechanical sensitivity in TTH. DPT was associated with widespread pressure sensitivity independently of the frequency of headaches supporting that deep dynamic pressure sensitivity within the trigeminal area is consistent with widespread pressure sensitivity. Assessing deep static and dynamic somatic tissue pain sensitivity may provide new opportunities for differentiated diagnostics and possibly a new tool for assessing treatment effects. SIGNIFICANCE: The current study found that dynamic pressure algometry in the temporalis muscle was associated with widespread pressure pain sensitivity in individuals with tension-type headache. The association was independent of the frequency of headaches. Assessing deep static and dynamic somatic tissue pain sensitivity may provide new opportunities for differentiated diagnostics and possibly a tool for assessing treatment effects.

Migraña como factor de riesgo cerebrovascular / Migraine as a cerebrovascular risk factor

Introducción: En los últimos años ha cobrado relevancia la migraña como factor de riesgo vascular así como la presencia de lesiones inespecíficas de sustancia blanca y lesiones isquémicas clínicamente silentes. Se ha intentado relacionar la presencia de estos hallazgos en la neuroimagen con la cronificación de la migraña. A esto hay que añadir la detección de un peor perfil metabólico en pacientes migrañosos. Con el fin de aclarar la relación entre la migraña y las alteraciones vasculares cerebrales, se ha realizado una exhaustiva revisión de la literatura. Desarrollo: Múltiples estudios han demostrado una asociación significativa entre la migraña, especialmente la migraña con aura (MCA), y el riesgo de infarto cerebral, sobre todo en mujeres < 45 años. El riesgo de ictus aumenta en presencia de otros factores asociados: más de 3 veces con hábito tabáquico y más de 4 veces con el consumo de anticonceptivos orales (ACO). La migraña puede causar directamente un infarto isquémico, aunque es infrecuente. La MCA tiene un riesgo 12 veces superior de infartos subclínicos en fosa posterior. Conclusiones: Como la migraña es un factor de riesgo vascular independiente, se presupone que un mejor control de la misma, así como de otros factores de riesgo vascular asociados, disminuirán la incidencia de ictus. Se aconseja un abandono del hábito tabáquico y suprimir el uso de ACO, sobre todo en mujeres con MCA. A pesar de todo, el riesgo absoluto de infarto es bajo y se traduce aproximadamente en 3,8 casos adicionales por cada 100.000 mujeres al año (AU)

Introduction: Migraine has become an important vascular risk factor during the past few years, along with the presence of white matter and clinically silent ischaemic lesions. Whether these findings contribute to the migraine becoming chronic has been a source of debate. People with chronic migraine also have a less favourable metabolic profile. An exhaustive review of the literature has been made in order to try to clarify the relationship between migraine and vascular risk factors.Development: Migraine, particularly with aura and in women < 45 years-old, is associated with an increased risk of cerebral infarction. This risk increases if the patient smokes or uses oral contraceptives. Migraine can also be a direct cause of a stroke, although it is an infrequent complication. Migraine with aura is associated with a risk factor of 12 of having subclinical infarctions in posterior foss circulation.Conclusions: Since migraine is an independent vascular risk factor, a better control of migraine attacks, as well as other possible concomitant vascular risk factors, should decrease the likelihood of a stroke. Overall, the real risk of infarction is low, with 3.8 new cases per 100,000 women and year (AU)

[Migraine as a cerebrovascular risk factor]. / Migraña como factor de riesgo cerebrovascular.

INTRODUCTION: Migraine has become an important vascular risk factor during the past few years, along with the presence of white matter and clinically silent ischaemic lesions. Whether these findings contribute to the migraine becoming chronic has been a source of debate. People with chronic migraine also have a less favourable metabolic profile. An exhaustive review of the literature has been made in order to try to clarify the relationship between migraine and vascular risk factors. DEVELOPMENT: Migraine, particularly with aura and in women < 45 years-old, is associated with an increased risk of cerebral infarction. This risk increases if the patient smokes or uses oral contraceptives. Migraine can also be a direct cause of a stroke, although it is an infrequent complication. Migraine with aura is associated with a risk factor of 12 of having subclinical infarctions in posterior fossa circulation. CONCLUSIONS: Since migraine is an independent vascular risk factor, a better control of migraine attacks, as well as other possible concomitant vascular risk factors, should decrease the likelihood of a stroke. Overall, the real risk of infarction is low, with 3.8 new cases per 100,000 women and year.

Migraine is comorbid with multiple sclerosis and associated with a more symptomatic MS course.

The objectives of this study were: (1) to assess relative frequency of migraine in multiple sclerosis (MS) patients using the validated self-administered diagnostic questionnaire, and to compare the migraine rates in MS outpatients to age- and gender-matched historical population controls; (2) to compare clinical and radiographic characteristics in MS patients with migraine and headache-free MS patients. We conducted a cross-sectional study to assess the demographic profiles, headache features and clinical characteristics of MS patients attending a MS clinic using a questionnaire based on the American Migraine Prevalence and Prevention (AMPP) study. We compared the relative frequency of migraine in MS clinic patients and AMPP cohort. We also compared clinical and radiographic features in MS patients with migraine to an MS control group without headache. Among 204 MS patients, the relative frequency of migraine was threefold higher than in population controls both for women [55.7 vs. 17.1%; prevalence ratio (PR) =3.26, p<0.001] and men (18.4 vs. 5.6%; PR=3.29, p<0.001). In a series of logistic regression models that controlled for age, gender, disease duration, ß-interferon use, and depression, migraine in MS patients was significantly associated (p<0.01) with trigeminal and occipital neuralgia, facial pain, Lhermitte's sign, temporomandibular joint pain, non-headache pain and a past history of depression. Migraine status was not significantly associated with disability on patient-derived disability steps scale or T2 lesion burden on brain MRI. Migraine is three-times more common in MS clinic patients than in general population. MS-migraine group was more symptomatic than the MS-no headache group.

Generalized neck-shoulder hyperalgesia in chronic tension-type headache and unilateral migraine assessed by pressure pain sensitivity topographical maps of the trapezius muscle.

Spatial changes in pressure pain hypersensitivity are present throughout the cephalic region (temporalis muscle) in both chronic tension-type headache (CTTH) and unilateral migraine. The aim of this study was to assess pressure pain sensitivity topographical maps on the trapezius muscle in 20 patients with CTTH and 20 with unilateral migraine in comparison with 20 healthy controls in a blind design. For this purpose, a pressure algometer was used to assess pressure pain thresholds (PPT) over 11 points of the trapezius muscle: four points in the upper part of the muscle, two over the levator scapulae muscle, two in the middle part, and the remaining three points in the lower part of the muscle. Pressure pain sensitivity maps of both sides (dominant/non-dominant; symptomatic/non-symptomatic) were depicted for patients and controls. CTTH patients showed generalized lower PPT levels compared with both migraine patients (P = 0.03) and controls (P < 0.001). The migraine group had also lower PPT than healthy controls (P < 0.001). The most sensitive location for the assessment of PPT was the neck portion of the upper trapezius muscle in both patient groups and healthy controls (P < 0.001). PPT was negatively related to some clinical pain features in both CTTH and unilateral migraine patients (all P < 0.05). Side-to-side differences were found in strictly unilateral migraine, but not in those subjects with bilateral pain, i.e. CTTH. These data support the influence of muscle hyperalgesia in both CTTH and unilateral migraine patients and point towards a general pressure pain hyperalgesia of neck-shoulder muscles in headache patients, particularly in CTTH.

[The hypothalamus in SUNCT syndrome: similarities and differences with the other trigeminal-autonomic cephalalgias]. / El hipotálamo en el SUNCT: similitudes y diferencias con las otras cefaleas trigeminoautonómicas.

INTRODUCTION: SUNCT belongs to the group of trigeminal-autonomic cephalalgias (TAC) --cluster headache and paroxysmal hemicranias--, since its shares a series of features with them. SUNCT was finally included in this group when the hypothalamus was proved to play a key role in its pathophysiology, an aspect that it has in common with other TAC. However, its clinical resemblance to trigeminal neuralgia of the first branch is notable, although it is accepted that the genesis of the trigeminal neuralgia is peripheral. DEVELOPMENT: The article presents the evidence available to date that has made it possible to associate the hypothalamus with SUNCT, as well as outlining its similarities and differences with respect to other TAC. This evidence is clinical, hormonal, from functional neuroimaging (activation of the posteroinferior hypothalamus) and from therapeutic outcomes (with deep hypothalamic stimulation). Likewise, a detailed description is provided of both the neuroanatomical bases (the hypothalamus as part of the neural networks involved in processes concerned with behaviour, memory, antinociceptive control, waking-sleep control and other circadian rhythms, etc.) and the neurochemical bases (orexins, somatostatin and endogenous opiates) that would support the hypotheses which researchers are attempting to establish to fit the evidence discussed earlier, which would have many points that overlap from one TAC to another. CONCLUSIONS: The question as to whether the hypothalamus is the/a generator of TAC or whether it is an element that allows its development remains open to debate, as does the issue of which would be the most plausible explanation for the phenotypic differences between them. Future studies will allow the enigma of SUNCT and the other TAC to be explained.

Aproximación clínica a las neuralgias craneales / A clinical approach to cranial neuralgias

Resumen. Introducción. La International Association for the Study of Pain define una neuralgia como el dolor sentido en el territorio de distribución de un nervio o raíz nerviosa. Aunque el criterio más importante para su diagnóstico es el espacial, es el conjunto de muchas características clínicas lo que nos va a permitir distinguir una neuralgia de otros dolores del área craneofacial. Desarrollo. Conocer los territorios de distribución sensitiva de los nervios o raíces es crítico para definir la localización del dolor en las neuralgias. Otros atributos también ayudan en su diagnóstico: la cualidad del dolor (paroxístico, urentequemante, sordo), el perfil temporal (segundos-minutos frente a horas-días), la ausencia de fenómenos acompañantes distintos de algunas manifestaciones de disfunción sensitiva, especialmente en las formas sintomáticas (hipoanestesia, parestesias, disestesias, alodinia, hiperalgesia, hiperpatía), la provocación del dolor por estímulos táctiles o mecánicos en el territorio doloroso (zonas ‘gatillo’) o la presencia de un signo de Tinel positivo, la respuesta al bloqueo anestésico del nervio o raíz y la respuesta a determinados fármacos. Conclusiones. Aunque la neuralgia trigeminal es la más frecuente, existen otras muchas neuralgias craneofaciales, teóricamente tantas como raíces nerviosas y nervios se encargan de la inervación sensitiva de estas regiones anatómicas. Su conocimiento es imprescindible para un correcto diagnóstico (AU)

Summary. Introduction. The International Association for the Study of Pain defines neuralgia as the pain that is felt in the distribution of a nerve or nerve root. Although the most important criterion for its diagnosis is spatial, distinguishing between neuralgia and other types of pain in the craniofacial area will only be possible by looking at a set of many clinical characteristics as a whole. Development. Knowledge of the territories of sensory distribution of the nerves or roots is essential to be able to define the location of the pain in neuralgias. Other attributes are also useful for diagnosing them: the quality of the pain (paroxysmal, stinging-burning, dull), the time profile (seconds-minutes versus hours-days), the absence of accompanying phenomena other than certain manifestations of sensory dysfunction, especially in the symptomatic forms (hypoanaesthesia, paresthesias, dysesthesias, allodynia, hyperalgesia, hyperpathy), pain triggered by tactile or mechanical stimuli in the painful territory (‘trigger’ zones) or a positive Tinel’s sign, the response to anaesthetic blockade of the nerve or root, and the response to certain drugs. Conclusions. Although trigeminal neuralgia is the most frequent, there are many other kinds of craniofacial neuralgias, in fact, theoretically, the total number is the same as the number of nerve roots and nerves responsible for the sensory innervation of these anatomical regions. It is essential to be familiar with them to obtain a correct diagnosis (AU)

[A clinical approach to cranial neuralgias]. / Aproximación clínica a las neuralgias craneales.

INTRODUCTION: The International Association for the Study of Pain defines neuralgia as the pain that is felt in the distribution of a nerve or nerve root. Although the most important criterion for its diagnosis is spatial, distinguishing between neuralgia and other types of pain in the craniofacial area will only be possible by looking at a set of many clinical characteristics as a whole. DEVELOPMENT: Knowledge of the territories of sensory distribution of the nerves or roots is essential to be able to define the location of the pain in neuralgias. Other attributes are also useful for diagnosing them: the quality of the pain (paroxysmal, stinging-burning, dull), the time profile (seconds-minutes versus hours-days), the absence of accompanying phenomena other than certain manifestations of sensory dysfunction, especially in the symptomatic forms (hypoanaesthesia, paresthesias, dysesthesias, allodynia, hyperalgesia, hyperpathy), pain triggered by tactile or mechanical stimuli in the painful territory ('trigger' zones) or a positive Tinel's sign, the response to anaesthetic blockade of the nerve or root, and the response to certain drugs. CONCLUSIONS: Although trigeminal neuralgia is the most frequent, there are many other kinds of craniofacial neuralgias, in fact, theoretically, the total number is the same as the number of nerve roots and nerves responsible for the sensory innervation of these anatomical regions. It is essential to be familiar with them to obtain a correct diagnosis.

Epicrania fugax: an ultrabrief paroxysmal epicranial pain.

Ten patients (one man and nine women, mean age 48.8 +/- 20.1) presented with a stereotypical and undescribed type of head pain. They complained of strictly unilateral, shooting pain paroxysms starting in a focal area of the posterior parietal or temporal region and rapidly spreading forward to the ipsilateral eye (n = 7) or nose (n = 3) along a lineal or zigzag trajectory, the complete sequence lasting 1-10 s. Two patients had ipsilateral lacrimation, and one had rhinorrhoea at the end of the attacks. The attacks could be either spontaneous or triggered by touch on the stemming area (n = 2), which could otherwise remain tender or slightly painful between the paroxysms (n = 5). The frequency ranged from two attacks per month to countless attacks per day, and the temporal pattern was either remitting (n = 5) or chronic (n = 5). This clinical picture might be a variant of an established headache or represent a novel syndrome.

[Determinants of prophylactic migraine therapy in Spain]. / Determinantes del uso de los fármacos con indicación para la profilaxis de la migrana en España.

INTRODUCTION: Migraine interferes with the quality of life of patients. Prophylactic medication is an option to be considered in cases showing inefficiency of symptomatic medication or an increase in the number of attacks. AIM: To evaluate the characteristics of patients that start on prophylactic treatment for migraine. PATIENTS AND METHODS: A multicenter epidemiologic survey was conducted in 110 neurological outpatient clinics and hospitals among adult patients of both sexes who required prophylactic treatment for migraine. Pain intensity was measured through a three-category scale: mild, moderate, or severe. Daily disability was measured by a disability questionnaire. RESULTS: A total of 735 patients with migraine who had started prophylactic treatment were considered valid for the analysis. The patients reported an average of 9.7 days with migraine in the previous month, 32% of the episodes lasting more than 24 hours. Half of the patients referred working or home disability due to migraine with a total average score of 15.1 on the disability scale (grade III). A 48% of the patients had previously received prophylactic treatment, the medications most commonly prescribed being flunarizine, propranolol and amitriptyline. At the study visit, the most commonly prescribed medications were topiramate, flunarizine, propranolol, and amitriptyline. CONCLUSIONS: Our study reveals that starting prophylactic treatment is in the majority of cases due to a high attack frequency. A clear evolution is being observed in prophylactic medication prescription, with a shift from flunarizine or propranolol to topiramate, which is prescribed more frequently nowadays.

[Symptomatic treatment of migraine with zolmitriptan: experience with 82 patients]. / Tratamiento sintomático de la migraña con zolmitriptán: experiencia con 82 pacientes.

OBJECTIVES: To analyze our experience with the new, 5 mg intranasal formulation of zolmitriptan in the symptomatic treatment of migraine attacks. PATIENTS AND METHODS: This series includes 82 patients who had treated an average of 7 migraine attacks. Eighty patients had taken oral triptans and 20 subcutaneous sumatriptan. The main reasons for using nasal zolmitriptan were: poor efficacy of oral triptans (41.5 % of the patients), use of subcutaneous sumatriptan (24.4%) or medical criteria (34.5%). RESULTS: Among the 80 patients who had been treated with oral triptans, 50 (62.5 %) preferred nasal zolmitriptan, 14 (17.5 %) oral triptans and the remaining 16 (20 %) did not express any preference. The main reasons for this preference were shorter speed of action and better efficacy. Within those 20 patients who were using subcutaneous sumatriptan, 8 (40 %) preferred subcutaneous sumatriptan, 5 (25%) nasal zolmitriptan and 7 (35%) did not express any preference. The reasons for preference of intranasal zolmitriptan over subcutaneous sumatriptan were greater convenience, better tolerability and lower price. A total of 55 patients noticed efficacy within 60 min. Half experienced at least one adverse event, always mild. The most frequent were local: bad taste (n=23) or nasal irritation/itching (n=8). CONCLUSIONS: The new intranasal formulation of 5 mg zolmitriptan is a good option for the symptomatic treatment of migraine, which could be considered as an intermediate between oral triptans and the subcutaneous formulation of sumatriptan.

Tratamiento sintomático de la migraña con zolmitriptán: experiencia con 82 pacientes / Symptomatic treatment of migraine with zolmitriptan: experience with 82 patients

Objetivos. Analizar nuestra experiencia con la nueva formulación nasal de zolmitriptán de 5 mg en el tratamiento sintomático de las crisis de migraña. Pacientes y métodos. La serie incluye 82 pacientes que habían tratado una media de siete crisis. Un total de 80 habían tomado triptanes orales y 20 sumatriptán subcutáneo. Las razones principales para la utilización de zolmitriptán nasal fueron: pobre eficacia de los triptanes orales (41,5% de los pacientes). de sumatriptán subcutáneo (24,4 %) o bien criterio médico (34,1%). Resultados. De los 80 pacientes que se habían tratado con triptanes orales, 50 (62,5%) prefirieron la formulación nasal de zolmitriptán, 14 (17,5%) los triptanes orales y los 16 restantes (20%) no expresaron preferencia. Las principales razones para la preferencia del zolmitriptán nasal fueron una mayor rapidez de acción y eficacia. De los 20 pacientes que usaban sumatriptán subcutáneo, 8 (40%) prefirieron éste, 5 (25 %) zolmitriptán nasal y 7 (35 %) no expresaron preferencia. Las razones para la preferencia de zolmitriptán nasal sobre sumatriptán subcutáneo fueron: mayor comodidad, menos efectos adversos y menor precio. Un total de 55 pacientes notaron eficacia antes de 60 mino La mitad de los pacientes aquejaron algún efecto adverso, siempre leves. Los más frecuentes fueron locales: mal sabor (n = 23) o irritación/picor nasal (n=8). Conclusiones. La formulación nasal de zolmitriptán de 5 mg es una nueva opción para el tratamiento sintomático de las crisis de migraña, que pudiéramos considerar como intermedia entre los triptanes orales y la formulación subcutánea de sumatriptán

Objectives: To analyze our experience with the new, 5 mg intranasal formulation of zolmitriptan in the symptomatic treatment of migraine attacks. Patients and methods: This series includes 82 patients who had treated an average of 7 migraine attacks. Eighty patients had taken oral triptans and 20 subcutaneous sumatriptan. The main reasons for using nasal zolmitriptan were: poor efficacy of oral triptans (41.5 % of the patients), use of subcutaneous sumatriptan (24.4%) or medical criteria (34.5%). Results: Among the 80 patients who had been treated with oral triptans, 50 (62.5 %) preferred nasal zolmitriptan, 14 (17.5 %) oral triptans and the remaining 16 (20 %) did not express any preference. The main reasons for this preference were shorter speed of action and better efficacy. Within those 20 patients who were using subcutaneous sumatriptan, 8 (40 %) preferred subcutaneous sumatriptan, 5 (25%) nasal zolmitriptan and 7 (35%) did not express any preference. The reasons for preference of intranasal zolmitriptan over subcutaneous sumatriptan were greater convenience, better tolerability and lower price. A total of 55 patients noticed efficacy within 60 min. Half experienced at least one adverse event, always mild. The most frequent were local: bad taste (n=23) or nasal irritation/itching (n=8). Conclusions: The new intranasal formulation of 5 mg zolmitriptan is a good option for the symptomatic treatment of migraine, which could be considered as an intermediate between oral triptans and the subcutaneous formulation of sumatriptan

[Experience with intranasal zolmitriptan in cluster headache]. / Experiencia con zolmitriptán nasal en la cefalea en racimos.

INTRODUCTION: The objective is to analyse our experience with the new intranasal formulation of zolmitriptan 5 mg in the symptomatic treatment of cluster headache in daily clinical practice. PATIENTS AND METHODS: We collected a total of 18 patients with cluster headache and experience with intranasal zolmitriptan; 17 had used subcutaneous sumatriptan and 8 oral triptans. The main reasons for trying intranasal zolmitriptan were: poor tolerability in 12 patients and insufficient efficacy in 6. RESULTS: Among the 17 patients experienced in subcutaneous sumatriptan, 12 (71 %) preferred nasal zolmitriptan, 2 (18 %) subcutaneous sumatriptan and 2 (12 %) did not express any preference. The reasons for preferring intranasal zolmitriptan were: higher convenience (n = 6), better tolerability (n = 5), lower price (n = 2) and higher efficacy (n = 1). Seven out of the 8 patients who had taken oral triptans preferred nasal zolmitriptan, in all cases due to higher subjective efficacy. A total of 11 patients showed efficacy within 30 minutes. Only 3 patients referred to adverse events, always mild. CONCLUSIONS: The 5 mg nasal formulation of zolmitriptan is a potential new option for the symptomatic treatment of cluster headache. This formulation should be considered in patients with poor tolerability to subcutaneous sumatriptan and in those attacks where quick access to inhaled oxygen is not possible. These results suggest that a controlled trial with nasal zolmitriptan in this indication would be worthwhile.

Síndrome de encefalopatía posterior reversible / Posterior reversible health care encephalopathy syndrome

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Duration of attacks of first division trigeminal neuralgia.

Objective measurements of duration of attacks have been performed in 8 (5 female and 3 male) patients suffering from primary first division (V-1) trigeminal neuralgia. The mean age of the patients was 67.5 +/- 11.4 years, and the mean age at onset 64.0 +/- 9.7 years. During the study the patients were off treatment. A total of 192 attacks were witnessed by the authors and exactly timed by a stop-watch. The duration of attacks ranged from 2 to 32 s, with a mean of 6.5 +/- 6.1 s. The unweighted mean was 8.8 +/- 5.7 s, with a range of 2.4-17.5 s. With the present data the duration of attacks of V-1 neuralgia has been exactly determined, and the clinical distinction of V-1 neuralgia from other shortlasting headaches, particularly from SUNCT, has been substantially clarified.

Objective assessment of autonomic signs during triggered first division trigeminal neuralgia.

A total of 26 episodes of V-1 trigeminal neuralgia attacks have been recorded in two female patients. Autonomic phenomena were assessed according to a semiquantitative scale. Attacks lasted 17 +/- 5 s. Mild lacrimation without conjunctival hyperaemia, rhinorrhea or ptosis was observed, even in relatively long lasting episodes. This is in clear contradiction with SUNCT (shortlasting, unilateral, neuralgiform headache with conjunctival injection, tearing and rhinorrhea) attacks that are always dramatically accompanied by both lacrimation and conjunctival injection of the symptomatic side from the very onset of symptoms. Carbamazepine provided complete and sustained relief of symptoms in both patients. Herein we will show differential autonomic features of V-1 trigeminal neuralgia vs. SUNCT that will both aid the clinician to distinguish both syndromes and stress that both entities are nosologicaly different.

Numular headache: a coin-shaped cephalgia.

Numular headache is a chronic, mild to moderate, pressurelike pain in a circumscribed cranial area of approximately 2 to 6 cm in diameter. Pain usually is limited to the parietal region, although it may appear in any cranial site. It is a benign process of usually unknown origin.

Supraorbital neuralgia: a clinical study.

A series of 18 patients suffering from supraorbital neuralgia have been studied through a seven year period. Appropriate investigations ruled out other headaches. There was a female (67%) preponderance. Mean age at onset was 51.6 years. The mean headache duration was 5.9 years. Five patients had a history of ipsilateral forehead trauma. The main areas of pain were the forehead and orbit. The pain was dull with short sharp or burning exacerbations. The temporal pattern was either remitting (n = 7) or chronic continuous (n = 11). Autonomic accompaniments were generally lacking. Neurological assessment was normal in all but 4 patients who were found to have signs/symptoms of sensory dysfunction in the forehead of the symptomatic side. Trials of different drugs, including migraine and anti-neuralgic drugs, only provided slight relief. Anaesthetic nerve blocks of the supraorbital nerve provided an absolute but transitory relief of pain. Although aetiology and pathogenesis of supraorbital neuralgia is largely unknown, entrapment of the supraorbital nerve at its outlet and successful decompressive surgery have been previously reported. This and other pathogenic hypotheses are discussed.